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TrainingFrontline StaffFamilyPsychoeducationU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services AdministrationCenter for Mental Health Serviceswww.samhsa.gov

TrainingFrontline StaffFamilyPsychoeducationU.S. Department of Health and Human ServicesSubstance Abuse and Mental Health Services AdministrationCenter for Mental Health Services

AcknowledgmentsThis document was prepared for the Substance Abuse and Mental Health Services Administration(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Departmentof Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served asSAMHSA Government Project Officers.DisclaimerThe views, opinions, and content of this publication are those of the authors and contributors anddo not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services(CMHS), SAMHSA, or HHS.Public Domain NoticeAll material appearing in this document is in the public domain and may be reproduced orcopied without permission from SAMHSA. Citation of the source is appreciated. However,this publication may not be reproduced or distributed for a fee without the specific, writtenauthorization from the Office of Communications, SAMHSA, HHS.Electronic Access and Copies of PublicationThis publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, pleasecall SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (Englishand Español).Recommended CitationSubstance Abuse and Mental Health Services Administration. Family Psychoeducation: TrainingFrontline Staff. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for Mental Health Services,Substance Abuse and Mental Health Services Administration, U.S. Department of Health andHuman Services, 2009.Originating OfficeCenter for Mental Health ServicesSubstance Abuse and Mental Health Services Administration1 Choke Cherry RoadRockville, MD 20857HHS Publication No. SMA-09-4422Printed 2009

Training Frontline StaffThis five-module workbook will help family intervention coordinatorsteach practitioners about the principles, processes, and skills necessaryto deliver effective Family Psychoeducation services. The workbookincludes the following topics:n Basic elements and practice principles;n The core processes of Family Psychoeducation;n Joining sessions and educational workshops;n Ongoing Family Psychoeducation sessions; andn Problem solutions from actual practice.FamilyPsychoeducationFor references see the booklet, The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs createdby the Center for Mental Health Services, Substance Abuse andMental Health Services Administration, U.S. Department of Healthand Human Services.This booklet is part of the Family Psychoeducation KIT that includesa DVD, CD-ROM, and seven booklets:How to Use the Evidence-Based Practices KITsGetting Started with Evidence-Based PracticesBuilding Your ProgramTraining Frontline StaffEvaluating Your ProgramThe EvidenceUsing Multimedia to Introduce Your EBP

What’s in Training Frontline StaffHow Family Intervention CoordinatorsShould Use This Workbook ....................APrepare program-specific information ................. BPrepare agency-specific information . . . . . . . . . . . . . . . . . .Visit an existing team . . . . . . . . . . . . . . . . . . . . . . . . . . . .Arrange for didactic training . . . . . . . . . . . . . . . . . . . . . . . DRecruit a consultant ..............................DCross-train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DCCFamilyPsychoeducationModule 1: Basic Elements and Practice Principles .....1What is Family Psychoeducation? . . . . . . . . . . . . . . . . . . . . 1The phases of Family Psychoeducation . . . . . . . . . . . . . . . . 2Practice principles ............................... 3The family experience ............................ 4Core values in Family Psychoeducation . . . . . . . . . . . . . . . . 4Program standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6How we know that Family Psychoeducation is effective. . . . . 6Adapting the evidence-based model .................. 7Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Exercise: Explore the Benefits of Family Psychoeducation . . . 9Exercise: Examine Program Standards ................ 11

Module 2: The Core Processesof Family Psychoeducation ....................1Identify consumers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Introduce the program . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Conduct joining sessions . . . . . . . . . . . . . . . . . . . . . . . . . . 3Conduct the educational workshop ................... 4Offer ongoing Family Psychoeducation services .......... 4Engage consumers and families continuously . . . . . . . . . . . 6Complete Progress Notes .......................... 7Participate in supervision .......................... 7Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Exercise: Identify Consumers and Families .............. 9Exercise: Introduce Your Program ................... 11Module 3: Joining Sessionsand Educational Workshops . . . . . . . . . . . . . . . . . . . 1Joining sessions ................................. 1Educational workshops . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Exercise: Review Progress Notes for Joining Sessionsand Educational Workshops ....................... 13Exercise: Practice What You’ve Learned AboutJoining Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Module 4: Ongoing Family Psychoeducation Sessions . . 1Conduct ongoing Family Psychoeducation sessions . . . . . . . 1Structure of multifamily groups . . . . . . . . . . . . . . . . . . . . . 2Overview of the first session ........................ 2Overview of the second session . . . . . . . . . . . . . . . . . . . . . 5Ongoing multigroup sessions ....................... 6Exercise: Practice What You’ve LearnedAbout Multifamily Groups . . . . . . . . . . . . . . . . . . . . . . . . 13Exercise: Review the Progress Note for Ongoing FamilyPsychoeducation Sessions ......................... 15Module 5: Problem Solutions from Actual Practice ....1Overview of the module . . . . . . . . . . . . . . . . . . . . . . . . . . 1Employment issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Medication issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Exercise: Practice What You’ve Learned AboutProblem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Training Frontline StaffHow Family Intervention CoordinatorsShould Use This WorkbookTraining Frontline Staff introducespractitioners to the basic principles andskills they need to deliver effective FamilyPsychoeducation (FPE) services. Use thisworkbook with the Practice DemonstrationVideo and the English or SpanishIntroductory Video on the DVD inthis KIT.Because being part of a team and learninghow to process information together areessential parts of FPE, we recommend thatyou conduct group training sessions ratherthan simply give FPE practitioners theworkbook to read on their own.To make the content easy to manage, wedivided the training into five modules.The Five FamilyPsychoeducation Modulesin Training Frontline Staff1 Basics Elements and PracticePrinciples.2 The Core Processes of FamilyPsychoeducation3 Joining Sessions and EducationalWorkshops4 Ongoing Family PsychoeducationSessions5 Problem Solutions from ActualPracticeTraining Frontline StaffA

How to Complete this Five-Session Trainingn Arrange for FPE practitioners to meet at least once a week for 5 weeks. You will cover up to one moduleeach week.n In this workbook, on the page before each module, you’ll find Notes to the family interventioncoordinator. Review the notes to prepare for the training.n Copy and distribute the module’s reading materials so that practitioners can read them beforethe training session. You’ll find this booklet on the KIT’s CD-ROM.n Copy the exercises for each module so that you can complete them during each trainingsession. You’ll find the exercises in this booklet on the KIT’s CD-ROM.n For each session, ask a different group member to facilitate.n Begin each training session by showing the corresponding segmentsof the Practice Demonstration Video.n Discuss the information on the video and in the workbook.n Complete the suggested exercises for that module.The ultimate purpose of this workbook is to havepractitioners understand the principles behind theFPE model, how FPE is delivered, and the skillsnecessary to provide effective services. We havefound that practitioners prefer to read one moduleat a time and then discuss that module withcolleagues as a group. Working through thesemodules as a group creates an opportunity todiscuss and master the core values and teachingprinciples that are essential to effective FPEpractice.Prepare program-specificinformationIn addition to providing the materials in thisworkbook, you should prepare to give FPEpractitioners information about FPE policiesand procedures. These include the following:n Procedures for identifying consumersfor the program;n Conditions under which consumers willbe discharged from the program;n Procedures for completing FPE Progress Notes;n Criteria for assessing the program’s fidelityto the FPE model; andn Outcomes that will be monitored.For sample forms, see Building Your Programand Evaluating Your Program in this KIT.B Training Frontline Staff

Prepare agency-specificinformationYou should also develop a plan to train practitionersabout other policies and procedures that may berelevant to the agency in which the FPE programoperates. These might include the following:n Consumers’ rights: Practitioners should beaware of the state and federal consumer rightsrequirements.n Billing procedures: Practitioners must knowhow to document and bill for FPE services.n Safety: Many agencies with existing communitybasedprograms have materials about safety.If training in this area is not already available,plan for training in de-escalation techniques.n Mandated reporting: Practitioners must knowhow to report suspected abuse and neglect. Theyalso must know what to do if they find out aboutother illegal activity and threats of harm to selfor others.n Other policies and procedures: Consult youragency’s human resources office to learn of otherprogram, agency, or state policies that the staffshould know.Visit an existing teamAfter your FPE team completes this workbook,we suggest that new practitioners observe anexperienced, high-fidelity FPE program. If youare familiar with these materials before your visit,your visit will be more productive. Rather thanusing time to explain the basics, the host programwill be able to show the new FPE practitionershow to apply the basics in a real-world setting.Arrange for didactic trainingAfter using this workbook and visiting anexperienced FPE program, FPE practitioners willbe ready for a trainer who will help them practicewhat they have seen and read. Some familyintervention coordinators choose to hire anexternal trainer to help their team practice FPEprinciples, processes, and skills. The initial trainingshould take 2 to 3 days.Recruit a consultantOnce FPE practitioners begin working withconsumers, you—along with the agency director—are responsible for ensuring that they follow theevidence-based model. This task can be challenging.You must facilitate a staff development process,apply what you have just learned about FPE in yourown clinical work with consumers, and, at the sametime, ensure through clinical supervision that FPEpractitioners follow the model.It is easy to stray from the evidence-based modeland do something similar to but not quite thesame as FPE. Sometimes this happens becausepractitioners believe they are diligently followingthe FPE model, but they miss some of the moresubtle aspects of it. In other cases, FPE servicesstart well, but, as more consumers are admittedto the program and pressure mounts, practitionersrevert to older, more familiar ways of working.To ensure that your team follows the FPE model,work with an experienced consultant throughoutthe first year of operation. A consultant can provideongoing telephone and in-person support to helpyou with your challenging leadership role.Training Frontline StaffC

Cross-trainIt is important that staff throughout your agencydevelop a basic understanding of FPE. Crosstrainingwill ensure that other staff memberssupport the work that the FPE team undertakes.As discussed in Building Your Program, we alsorecommend that you train members of your FPEadvisory group. The more information that advisorygroup members have about FPE, the better theywill be able to support the program and its mission.Training is also an opportunity for FPEpractitioners and advisory group members tobecome familiar with one another. Make sure thatthe advisory group members and FPE practitionersintroduce themselves and that they are familiarwith each other’s roles.To help you conduct your training, we include thesemultimedia materials in the FPE KIT:n Introductory PowerPoint presentation;n Sample brochure; andn Introductory Video.For more informationThe information in this workbook provides adetailed overview of the FPE model. For moreinformation, see the following resources:Anderson, C., Hogarty, G., & Reiss, D. (1986).Schizophrenia and the family. New York:Guilford Press.McFarlane, W. R., (Ed.). (2002). Multifamilygroups in the treatment of severe psychiatricdisorders. New York: Guilford.We consistently found that agencies used theseadditional resources with this KIT to developand manage their FPE programs. For this reason,we recommend the first resource to thoseimplementing FPE in a single-family format andthe second resource to those implementing FPEin the multifamily group format. For additionalresources, see The Evidence in this KIT.Once trained, you or your staff will be able touse these materials to present routine, inserviceseminars to ensure that all staff members withinthe agency and advisory group members arefamiliar with the FPE program.D Training Frontline Staff

Module 1Basics Elements and Practice PrinciplesNotes to the family intervention coordinatorPrepare for Module 1:n Make copies of Module 1. Your copyis in this workbook; print additionalcopies from the KIT’s CD-ROM.n Distribute the material to the FPE practitionerswho will participate in your group session. Askthem to read it before meeting as a group.n Make copies of these exercises:o Explore the Benefits of FamilyPsychoeducationo Examine Program Standardsn Make copies of these documentsfound in Evaluating Your Programin this KIT:o The Family Psychoeducation Fidelity Scaleo General Organizational Indexo Outcome measures that your agencywill monitor (if available)Do not distribute them until your group training .Facilitating the dialogue: One of theroles of a family intervention coordinatoris to facilitate the dialogue during grouptraining sessions. Some people have difficultyspeaking in a group, perhaps because theyare timid or soft-spoken. Others may feelprofessionally intimidated by those with moreexperience or higher degrees. Conversely,some practitioners will be self-confident andoutspoken and will need to learn to listenopenly to what others have to say.As you work together on each module,encourage those who are more withdrawnto express their views and make sure thatthe more vocal people give others a chanceto speak. Group training also gives you theopportunity to assess the anxiety that FPEpractitioners may feel about providing FPEservices. Use your group training time toexplore and address issues openly.Conduct your first session:n When you convene your group, viewthe Introductory Video. Discuss thevideo and the content of Module 1.n Distribute the following:o The Family Psychoeducation Fidelity Scaleo General Organizational Indexo Outcome measures that your agency willmonitor (if available)o The exercises for this modulen Review the distributed materials and completethe exercises as a group.Basic Elements and Practice Principles E Module 1

Training Frontline StaffModule 1: Basic Elements and Practice PrincipalsModule 1 explains the basic elements of Family Psychoeducation, including thepractice principles of the model. This module orients practitioners to how consumersand families may benefit from the evidence-based practice.What is FamilyPsychoeducation?Family Psychoeducation (FPE) is anapproach for partnering with consumersand families to treat serious mentalillnesses. FPE practitioners developa working alliance with consumersand families.The term psychoeducation can bemisleading. While FPE includes manyworking elements, it is not family therapy.Instead, it is nearly the opposite. In familytherapy, the family itself is the object oftreatment. But in the FPE approach, theillness is the object of treatment, not thefamily. The goal is that practitioners,consumers, and families work togetherto support recovery.Serious mental illnesses such asschizophrenia, bipolar disorder, and majordepression are widely accepted in themedical field as illnesses with wellestablishedsymptoms and treatment.As with other disorders such as diabetesor hypertension, it is both honest and usefulto give people practical information abouttheir mental illnesses, how common theyare, and how they can manage them.Many consumers and families report thatthis information is helpful because it letsthem know that they are not alone and itBasic Elements and Practice Principles 1 Module 1

empowers them to participate fully in the recoveryprocess. Similarly, research shows that consumeroutcomes improve if families receive informationand support (Dixon et al., 2001). For this reason,a number of family psychoeducation programs havebeen developed over the past two decades.Models differ in their format (whether they usemultifamily or single-family format); duration oftreatment; consumer participation; and location.Research shows that the critical ingredients ofeffective FPE include the following (Dixon etal., 2001):n Education about serious mental illnesses;n Information resources, especially during periodsof crises;n Skills training and ongoing guidance aboutmanaging mental illnesses;n Problem-solving; andn Social and emotional support.The phases of FamilyPsychoeducationFPE services are provided in three phases:n Joining sessions;n An educational workshop; andn Ongoing FPE sessions.Joining sessionsInitially, FPE practitioners meet with consumersand their respective family members in introductorymeetings called joining sessions. The purpose ofthese sessions is to learn about their experienceswith mental illnesses, their strengths and resources,and their goals for treatment.FPE practitioners engage consumers and familiesin a working alliance by showing respect, buildingtrust, and offering concrete help. This workingalliance is the foundation of FPE services.Joining sessions are considered the first phaseof the FPE program.Educational workshopIn the second phase of the FPE program, FPEpractitioners offer a 1-day educational workshop.The workshop is based on a standardizededucational curriculum to meet the distincteducational needs of family members.FPE practitioners also respond to the individualneeds of consumers and families throughout theFPE program by providing information andresources. To keep consumers and families engagedin the FPE program, it is important to tailoreducation to meet consumer and family needs,especially in times of crisis.Ongoing Family Psychoeducation sessionsAfter completing the joining sessions and 1-dayworkshop, FPE practitioners ask consumersand families to attend ongoing FPE sessions.When possible, they offer ongoing FPE sessionsin a multifamily group format. Consumers andfamilies who attend multifamily groups benefitby connecting with others who have similarexperiences. The peer support and mutualaid provided in the group builds social supportnetworks for consumers and families who areoften socially isolated.Ongoing FPE sessions focus on current issues thatconsumers and families face, and address themthrough a structured problem-solving approach.This approach helps consumers and families makegains in working toward consumers’ personalrecovery goals.FPE is not a short-term intervention. Studies showthat offering fewer than 10 sessions does notproduce the same positive outcomes (Cuijpers,1999). We currently recommend providing FPEfor 9 months or more.Module 1 2 Basic Elements and Practice Principles

In summary, FPE practitioners provide informationabout mental illnesses, and help consumersand families enhance their problem-solving,communication, and coping skills. When providedin the multifamily group format, ongoing FPEsessions also help consumers and families developsocial supports.Practice principlesFPE is based on a core set of practice principles.These principles form the foundation of theevidence-based practice and guide practitionersin delivering effective FPE services.Practice PrinciplesPrinciple 1:Consumers definewho family is.Principle 2:The practitionerconsumer-familyalliance is essential.Principle 3:Education andresources help familiessupport consumers’personal recovery goals.Principle 4:Consumers and familieswho receive ongoingguidance and skillstraining are better ableto manage mentalillnesses.Principle 5:Problem-solving helpsconsumers and familiesdefine and addresscurrent issues.Principle 6:Social and emotionalsupport validatesexperiences andfacilitates problemsolving.In FPE, the term family includes anyone consumers identify as being supportive in therecovery process. For FPE to work, consumers must identify supportive people they wouldlike to involve in the FPE program. Some consumers may choose a relative. Others mayidentify a friend, employer, colleague, counselor, or other supportive person.Consumers and families have often responded to serious mental illnesses with great resolveand resilience. FPE recognizes consumer and family strengths, experience, and expertise inliving with serious mental illnesses.FPE is based on a consumer-family-practitioner alliance. When forming alliances withconsumers and families, FPE practitioners emphasize that consumers and families arenot to blame for serious mental illnesses. Blaming consumers or families is not constructiveor helpful and should be avoided. FPE practitioners partner with consumers and familiesto better understand consumers and support their personal recovery goals.Consumers benefit when family members are educated about mental illnesses. Educatedfamilies are better able to identify symptoms, recognize warning signs of relapse, supporttreatment goals, and promote recovery. Provide information resources to consumers andfamilies, especially during times of acute psychiatric episodes or crisis.Consumers and families experience stress in many forms in response to mental illnesses.Practical issues such as obtaining services and managing symptoms daily are stressors.Learning techniques to reduce stress and improve communication and coping skillscan strengthen family relationships and promote recovery. Learning how to recognizeprecipitating factors and prodromal symptoms can help prevent relapses. For moreinformation, see Training Frontline Staff in this KIT.Using a structured problem-solving approach helps consumers and families breakcomplicated issues into small, manageable steps that they may more easily address.This approach helps consumers take steps toward achieving their personal recovery goals.FPE allows consumers and families to share their experiences and feelings. Social andemotional support lets consumers and families know that they are not alone. Participants inFPE often find relief when they openly discuss and problem-solve the issues that they face.Basic Elements and Practice Principles 3 Module 1

The family experienceMental illnesses bring about such significantchanges in people’s lives that many families thinkin terms of how life was before and after the onsetof the illness. Families often provide emotional andinstrumental support, case management functions,financial assistance, advocacy, and housing torelatives with mental illnesses. Doing so can berewarding, but also imposes considerable stress.Family members often find that they lack access toneeded resources and information. Stressors rangefrom practical problems such as paying medicalbills and obtaining services to issues related to thesymptoms of mental illnesses.Family members also must cope with their ownemotional responses to having a relative withmental illnesses. Emotional responses vary fromoptimism and hope to denial, guilt, and grief(Tessler & Gamache, 2000; Hatfield & Lefley,1987). These feelings may interfere with theircapacity to support and help their relative inthe recovery process.In addition, consumers and families may facestigma while coping with serious mental illnesses.They may find that friends and relatives beginto avoid them. They may isolate themselves fromnatural support networks if they perceive thatothers cannot relate to their experiences.Stigmatization and isolation can lead people tofeel exasperated, abandoned, and demoralized.Stress, isolation, and stigma can cause tension anddisagreements between consumers and families.Disagreements can be destabilizing or, at least, canprevent rehabilitation if they are left unresolved.Therefore, addressing these issues not only helpsto improve the overall functioning of the family butalso promotes recovery.FPE addresses these issues by focusing onconsumer and family strengths. Consumers andfamilies often show great resolve and resiliencewhen faced with crises related to mental illnesses.They demonstrate more adaptive coping whenthey feel affirmed, respected, and valued for theinformation and skills that they possess. For thisreason, FPE sees families as partners and asksthem to share their resources and expertise tohelp consumers achieve their recovery goals.Core values in FamilyPsychoeducationFPE is based on several core values that permeatethe relationship among consumers, families, andpractitioners. These values include the following:n Building hope;n Recognizing consumers and families as expertsin their own experience of mental illnesses;n Emphasizing personal choice;n Establishing a collaborative partnership; andn Demonstrating respect.Build hopeThe long-term course of mental illnesses cannotbe predicted, and no one can predict anyone’sfuture. However, studies suggest that consumersand families who actively participate in theirtreatment and who develop effective coping skillshave the most favorable course and outcome,including a better quality of life (Mueser et al.,2002). The ability to influence your own destiny isthe basis for hope and optimism about the future.FPE practitioners convey hope and optimism toconsumers and their families. In providing FPE,practitioners present information and skills as beingpotentially useful tools that consumers can usein pursuing their goals. Informed and involvedfamilies will feel more empowered to supporttheir relatives’ recovery goals. FPE practitionerskeep an attitude of hope and optimism, evenwhen consumers and families may be pessimistic.Module 1 4 Basic Elements and Practice Principles

Recognize consumers and familiesas expertsWhile FPE practitioners have professional expertiseabout information and skills for managing andrecovering from mental illnesses, consumersand families have experience in living with mentalillnesses. Consumers and families know whichstrategies have worked in the past for them andwhich have not.FPE practitioners encourage consumers andfamilies to share their unique experiences withmental illnesses and response to treatment. Bypaying close attention to consumers’ and families’expertise, you can more effectively help consumersprogress toward their personal goals.Emphasize personal choiceThe overriding goal of FPE is to support consumersin their personal recovery process. The ability andright of consumers to make their own decisions isparamount, even when consumers’ decisions differfrom the recommendations of their family andpractitioners. Certain rare exceptions to thisprinciple do exist, for example, when legalconstraints such as an involuntary hospitalizationprotect consumers from themselves or others.In general, avoid pressuring consumers to makecertain treatment decisions and encourage familiesto do the same. Instead, accept consumers’decisions and work with them to evaluate theconsequences in terms of their personal goals.Keeping the emphasis on consumers’ personalchoice is key to establishing and maintaining astrong alliance with both consumers and families.FPE practitioners model how respecting consumerchoices, despite disagreements, builds a trustingrelationship that promotes positive change.Establish a collaborative partnershipWhile FPE practitioners serve a variety of roles,they are primarily collaborators. The collaborativespirit of FPE reflects the fact that consumers,families, and practitioners work side by side ina nonhierarchical relationship.FPE practitioners establish a working alliance withconsumers and families. Together, they learn howto cope with the unique characteristics ofconsumers’ mental illnesses and make progresstoward their personal recovery goals.Demonstrate respectRespect is a key ingredient for successfullycollaborating in FPE. FPE practitioners respectconsumers and families as human beings, capabledecisionmakers, and partners in the treatmentprocess. FPE practitioners accept that consumersand families may differ in their personal valuesand opinions. They respect consumers’ andfamilies’ right to their own values and opinions.For example, consumers may disagree that theyhave a particular mental illness or that they haveany mental illness at all.Rather than actively trying to persuade consumersthat they have a specific disorder, FPE practitionersrespect their beliefs while searching for commonground as a basis for collaboration. Such commonground could include the following:n Symptoms and distress that consumersexperience (perhaps even conceptualizedgenerally as stress, anxiety, or nerve problems);n Desire to avoid hospitalization;n Difficulties with independent living; orn Specific goals they would like to accomplish.By seeking common ground, FPE practitionersdemonstrate respect for consumers’ beliefs andtheir right to make informed decisions based ontheir values and beliefs.Basic Elements and Practice Principles 5 Module 1

Program standardsOne of the unique features of FPE is that theimportant characteristics of this evidence-basedmodel have been translated into program standardsto help programs replicate effective services.An instrument called the FPE Fidelity Scalesummarizes these characteristics and is availableto help quality assurance teams assess how closelytheir program follows the evidence-based model(See Evaluating Your Program in this KIT). Yourfamily intervention coordinator will give this scaleto you to review and discuss during training.Basic Characteristics of FamilyPsychoeducationn Family intervention coordinatorn Session frequencyn Long-term FPEn Quality of consumer-family-practitioneralliancen Detailed family reactionn Precipitating factorsn Prodromal signs and symptomsn Coping strategiesn Educational curriculumn Multimedia educationn Structured group sessionsn Structured problem-solvingn Stage-wise provision of servicesHow we know that FamilyPsychoeducation is effectiveFPE is based on research that shows that familiesand consumers who participated in the componentsof the evidence-based model experienced 20 to 50percent fewer relapses and rehospitalizations thanthose who received standard individual servicesover 2 years (Penn & Mueser, 1996; Dixon &Lehman, 1995; Lam, Kneipers, & Leff, 1993;Falloon et al., 1999). Those at the higher end ofthis range participated for more than 3 months.Studies also show that FPE improved family wellbeing(Dixon et al., 2001; McFarlane et al., 2003).Families reported greater knowledge of seriousmental illnesses; a decrease in feeling confused,stressed, and isolated; and reduced medical illnessand medical care utilization (Dyck, Hendryx, Short,Voss, & McFarlane,,2002).FPE has been found to increase consumers’participation in vocational rehabilitation programs(Falloon et al., 1985). Studies have shownemployment rate gains of two to four times baselinelevels, when combined with the evidence-basedpractice, Supported Employment (McFarlane etal., 1996; McFarlane et al., 1995; McFarlane etal., 2000).Based on this significant evidence, treatmentguidelines recommend involving families in thetreatment process by offering the criticalingredients outlined in this evidence-based model(Lehman & Steinwachs, 1998; American PsychiatricAssociation, 1997; Weiden, Scheifler, McEvoy,Allen, & Ross, 1999).n Assertive engagement and outreachModule 1 6 Basic Elements and Practice Principles

Adapting the evidence-basedmodelResearch has shown the greatest amount ofbenefits rom FPE for families and consumerswith schizophrenic disorders (Dixon et al., 2001).For this reason, we recommend that newpractitioners first provide FPE services toconsumers with these disorders.Once practitioners have learned this approach byworking with people with schizophrenia, they findit relatively easy to modify it for other disorders.Studies show that FPE may be effectively adaptedand used for the following disorders:n Bipolar disorder (Clarkin, Carpenter, Hull,Wilner, & Glick, 1998; Miklowitz & Goldstein,1997; Moltz, 1993; Parikh et al., 1997; Miklowitzet al., 2000; Simoneau, Miklowitz, Richards,Saleem, & George, 1999);n Major depression (Simoneau et al., 1999;Emanuels-Zuurveen & Emmelkamp, 1997;Leff et al., 2000);n Obsessive-compulsive disorder (Van Noppen,1999); andn Borderline personality disorder (Gunderson,Berkowitz, & Ruizsancho, 1997).SummaryThis module reviewed the basic elements and corevalues of FPE. This evidence-based practice isbased on a core set of practice principles, whichhave been translated into program standards thatagencies may replicate. Substantial research hasdemonstrated its effectiveness.The next modules give practitioners informationabout the core processes for providing FPE services.This model also has been adapted and usedeffectively in a variety of countries and cultures.For more information about diagnosis-specificor cultural adaptations of this model, see TheEvidence in this KIT.Basic Elements and Practice Principles 7 Module 1

Exercise: Explore the Benefits of Family PsychoeducationStudies that have explored what makes a difference in whether practitioners adopt a new approach totreatment have found that practitioners are more likely to adopt a practice if it addresses an area in whichthey feel they must improve. Share your experiences about where the traditional service delivery systemhas been inadequate and identify aspects of FPE that address those inadequacies.Some experiences where the traditional service delivery system has been inadequate:nnnnnnHow Family Psychoeducation may address those inadequacies:nnnnnnBasic Elements and Practice Principles 9 Module 1

Exercise: Examine Program Standardsn Distribute these documents:o Family Psychoeducation Fidelity Scale;o General Organizational Index; ando Outcome measures that your agency will monitor (if available).n Discuss how your Family Psychoeducation program will be evaluated based on these program standards.Basic Elements and Practice Principles 11 Module 1

Module 2The Core Processes of Family PsychoeducationNotes to the family intervention coordinatorPrepare for Module 2:n Make copies of Module 2. Your copyis in this workbook; print additionalcopies from the CD-ROM in the KIT.n Distribute the material to those who areparticipating in your group training. Ask themto read it before meeting as a group.n Make copies of these exercises:o Identify Consumers and Familieso Introduce Your ProgramConduct your second session:n When you convene your group, discuss thecontent of Module 2.n Distribute the following:o Your agency’s policies and procedures foridentifying consumers for FPE and dischargingthem from the programo Exercises for this moduleNote: This module has no corresponding PracticeDemonstration Video component.Do not distribute the exercises until the grouptraining. Your copies are in this workbook;print additional copies from the KIT’s CD-ROM.n Make copies of your agency’s policies andprocedures for identifying consumers forFPE and discharging them from the program(if available). Guidelines for developing thesepolicies are provided in Building Your Programin this KIT.The Core Processes of Family Psychoeducation 13 Module 2

Training Frontline StaffModule 2: The Core Processesof Family PsychoeducationModule 2 introduces you to the core processes of Family Psychoeducation, includingjoining with consumers and families, offering education, and understanding thenature of ongoing Family Psychoeducation (FPE) sessions. This module also discussesthe goals and objectives of each phase of the program.Core processes of Family Psychoeducationn Consumers are identified as potentialparticipants.n Practitioners introduce FamilyPsychoeducation to consumers.Consumers who are willing toparticipate identify potential familymembers.n Practitioners meet individually threeor more times with consumers andfamilies. The purpose of these joiningsessions is to engage consumers andfamilies in a working alliance.n Once practitioners have finishedjoining sessions with five to eightconsumers and their respectivefamilies, they offer a 1-dayeducational workshop.n After completing the 1-dayeducational workshop, practitionersask consumers and families to attendongoing Family Psychoeducationsessions offered in either single-familyor multifamily group format.n Ongoing Family Psychoeducationsessions continue for 9 months ormore. Practitioners, consumers, andfamilies use a structured problemsolvingapproach to define andaddress current issues.n Practitioners document consumers’progress using Progress Notes tailoredto each phase of the program.n Practitioners meet weekly with thefamily intervention coordinator forgroup supervision.The Core Processes of Family Psychoeducation 1 Module 2

Although you might think that integrating FamilyPsychoeducation (FPE) core processes andpaperwork into your daily routine is too timeconsuming and burdensome, these processesensure that FPE services are effective and efficient.Identify consumersFPE is effective for a wide variety of consumers.However, some evidence shows that FPE isparticularly beneficial for consumers and familieswith the following characteristics:n Consumers who have recently experienced theirfirst episode of mental illness or are early in thecourse of illness;n Consumers who are experiencing acutepsychiatric crisis;n Consumers who experience frequenthospitalizations or prolonged unemployment;n Consumers or families who have asked to learnmore about serious mental illnesses;n Families who have previously benefited froma family education program and want to learnhow to better support their relative; orn Families who are especially exasperatedor confused about the illness.FPE is particularly effective in working withfamilies and consumers who are early in the courseof illness, because most consumers and familiesreport the most extreme distress during this time.Often in this early period, major rifts developbetween consumers and families that mayexacerbate symptoms and disability. FPE hasprevented and often healed those rifts, asparticipants stop blaming themselves or oneanother and cooperate to help in the overalltreatment and rehabilitation process.Initially many agencies choose to offer FPE toconsumers with schizophrenic disorders becausethe evidence for this model is strongest with thisgroup. Once you have provided FPE services toconsumers with schizophrenic disorders and theirfamilies, it relatively easy to modify your FPEprogram to provide services to families andconsumers who have other diagnoses.The number and types of consumers you identifydepend on whether you offer FPE in a multifamilyor single-family group format. If your agencyintends to offer ongoing FPE services primarilyin the multifamily format, identify five to eightconsumers with similar diagnoses and offermultifamily group sessions to them. If your agencychooses to offer FPE in a single-family format, thenumber of consumers you should identify dependson the size of your FPE program.During this training, your family interventioncoordinator will review your agency’s policies andprocedures for identifying consumers for FPE.Introduce the programOnce your family intervention coordinator assignsconsumers to your caseload, set up a face-to-facemeeting to introduce them to the FPE program.In the meeting, emphasize that the program is forboth consumers and their family members. Whilesome psychoeducation programs are solely foreither consumers or family members, FPE servicesare provided to both simultaneously.Emphasize that participating in FPE is theconsumers’ choice. After discussing the benefitsand structure of the FPE program, ask consumersif they would like to identify a family memberwith whom they would participate in the program.Remember, the term family includes anyone whoconsumers believe is supportive and would like toModule 12 2 The Core Basic Processes Elements of Family and Practice Psychoeducation Principles

participate in FPE. Therefore, consumers mayidentify people who are not blood relatives.Most consumers welcome family involvement whenit is clear that the goal is to help families betterunderstand their illness and build support to helpthem achieve their personal recovery goals.However, if consumers are not interested in theprogram, respect their decision.ConfidentialitySome states require that consumers sign a Releaseof Information Form before you may contact theirfamily member. Your family interventioncoordinator should review your agency’sconfidentiality requirements as a part of thistraining. For more information, see Building YourProgram in this KIT.Length of the FPE programAlthough the goal is to offer ongoing FPE services,some consumers and families may be initiallyunwilling to make long-term commitments.Instead, when you introduce FPE, simply askconsumers and families to participate for as long asthey find it useful. Often once people participatefor a few sessions, they choose to stay long term,especially in multifamily groups.Conduct joining sessionsOnce consumers agree to participate in FPE andidentify a family member, arrange to meet withthem. These initial introductory sessions are calledjoining sessions.Joining sessions are considered the first phase ofthe FPE program. Complete this phase by meetingwith consumers and families at least three times forapproximately 1 hour.The overall purpose of joining sessions is toengage consumers and families in a workingalliance. This working alliance is essential toproviding effective FPE.Each joining session has distinct goals andobjectives (see Module 3). Some of the goalsof joining sessions are as follows:n Understand consumers’ and families’ uniqueexperiences and view of mental illnesses;n Learn about consumer and family strengthsand resources in coping with mental illnesses;n Develop mutual, specific goals; andn Instill hope and an orientation toward recovery.You may hold joining sessions with consumers andtheir respective family members together or meetseparately with them. (That means you wouldconduct six or more sessions instead of threeor more.)When deciding whether to meet with consumersand families jointly or separately, consider thefollowing:n Consumer and family preferences;n Consumer diagnosis and illness characteristics;andn The goals of the session.Tell consumers and families that it is common tomeet with them individually and jointly with theirrespective family members in the first phase of theFPE program. Ask consumers and families how theyfeel about joint and separate meetings. Logisticalarrangements such as transportation or workschedules sometimes dictate whether consumersand families can meet jointly. Discuss preferencesand logistical factors during your first meeting.Decisions for offering joining sessions separatelyor jointly are also based on diagnosis and illnesscharacteristics. For example, recent studies showthat joining sessions for consumers with bipolardisorder are more effective when conductedThe Core Processes of Family Psychoeducation 3 Module 2

separately (Moltz, 1993). Use your professionaldiscretion to determine how best to accomplishthe goals of each session. See Module 3 for moreinformation.It is important to fully complete this phase beforeyou offer ongoing FPE sessions. Practitionerswho shortchange this process often experiencedifficulties keeping consumers and familiesengaged in FPE services.Conduct the educationalworkshopOnce you meet the goals of the joining sessions,you are ready to offer the second phase of theFPE program. In this phase, you will ask familymembers to attend a 1-day educational workshop.Following a structured educational curriculum,the workshop is usually conducted in a formal,classroom setting. Two FPE practitioners who havecompleted joining sessions with consumers andfamilies facilitate the workshop. The treatingpsychiatrist and other treatment team membersare often invited to conduct part of the presentation.For more information about the structure andcontent of this workshop, see Module 3.Typically the workshop is conducted solely withfamilies—not with consumers—to give familiesa chance to get acquainted. The opportunity tointeract with others who are in similar situationsand to speak freely about their experiencesallows families to bond and develop supportiverelationships. It also increases families’commitment to participate in FPE.Some agencies involve consumers in part of theworkshop to ensure that they receive the sameeducational information as their families. Othersoffer this information to consumers individuallyor in a separate consumer forum.Use professional discretion to decide whicheducational format will be most effective for theconsumers in your program. Consider the severityof consumers’ symptoms and their cognitive abilityto absorb educational material when it is providedin the joint format. For example, recent studiesshow that joint educational sessions are effectivefor consumers with nonepisodic bipolar disorder(Moltz, 1993; Miklowitz & Goldstein, 1997).If you plan to offer ongoing FPE sessions in amultifamily group format, complete at least threejoining sessions with five to eight consumers andtheir respective family members before conductingthe 1-day workshop. To ensure that consumers andfamilies remain engaged, offer the workshop within1 or 2 weeks after you complete the joining sessions.You may need to carefully coordinate this.Offer ongoing FamilyPsychoeducation servicesAfter completing three joining sessions and the1-day workshop, ask consumers and families toattend ongoing FPE sessions. The third phaseof the FPE program consists of providing ongoingFPE sessions for 9 months or more. You mayprovide these sessions in either the single-familyor multifamily group format.Choose a formatThe format that you choose will depend onconsumer and family preferences and needs.In general, single-family formats tend to be usedfor the following:n Consumers and families with strong socialsupport networks;n Consumers and families who exhibit unusualresilience or strong coping skills; orn Consumers who response positivelyto medications;Module 12 4 The Core Basic Processes Elements of Family and Practice Psychoeducation Principles

Multifamily groups tend to be used for thefollowing:n Consumers who are experiencing their firstepisode with mental illness;n Consumers who are not responding wellto medication and treatment;n Consumers who are experiencing othercomplicating issues such as additionalmedical illnesses;n Families experiencing high stress;n Families who have separated from theirrelative with mental illness; andn Families who have been through divorce.Although initially consumers and families maybe reluctant to participate in a group, multifamilygroups benefit both consumers and their families.For example, the social stigma related to mentalillnesses causes many consumers and families tofeel socially isolated. FPE in a multifamily groupformat connects consumers and families to otherswith similar experiences. It gives them a forumfor peer support and mutual aid by allowingparticipants to share solutions that have workedfor them. For this reason, we recommend offeringongoing FPE services in a multifamily groupformat, whenever possible.FPE multifamily groups consist of five to eightconsumers and their respective family members.They meet every 2 weeks for 1½ hours. Two FPEpractitioners co-facilitate the group.In the single-family format, one FPE practitionermeets with one consumer and his or her familymembers. Meetings are usually every 2 weeksfor 1 hour.FPE practitioners commonly work in bothmultifamily or single-family group formats.For example, when multifamily group membersare unable to attend specific group sessions, youmay offer single-family sessions to accommodatescheduling difficulties.Use single-family sessions to re-engage consumersand families who no longer participate in FPEservices. You may also offer single-family sessionsto consumers and families who have completedan FPE multifamily group. Offer these sessionsas needed to sustain ongoing family supportand involvement.If your agency is only able to offer ongoing FPE ina single-family format, refer consumers and familiesto local support groups to ensure that they canbenefit from peer support and mutual aid.Focus on current issuesThe goal of ongoing FPE sessions is to identify thecurrent issues that consumers and families face, andto partner with them to address these issues. FPEpractitioners commonly use a structured problemsolvingapproach, provide information, and teachcommunication, coping, and social skills.In general, FPE sessions reinforce the informationlearned in the educational workshop and focuson consumers’ personal recovery goals, whichgenerally fall into the following categories:n Issues related to re-entering the community; orn Issues related to social and vocationalrehabilitation.Issues related to re-entering the communityConsumers who are experiencing or recoveringfrom acute episodes for which they have beenhospitalized often have issues related to re-enteringthe community. Personal recovery goals may relateto the following:n Coping with symptoms;n Medication; andn Alcohol and substance use.At times, the symptoms of mental illnesses mayinterfere with consumers’ ability to processinformation presented either verbally or in writing.The Core Processes of Family Psychoeducation 5 Module 2

Consequently, communication issues are common.Use communication and coping skills training toaddress these issues.Communication skills training helps consumersand families learn new methods of interactingto address cognitive difficulties. These skillsare especially useful for consumers who haveexperienced complications or have not respondedwell to treatment. Their families may feelexasperated and, consequently, may exacerbatetheir relative’s symptoms.In ongoing FPE sessions, model simple and directcommunication for family members. Reinforce theimportance of communicating in a low, calm toneto counteract sensitivity to stimulation. Othertechniques include breaking information down intosmall chunks and engaging consumers to ensurethat they receive information accurately.When communicating important ideas, encourageconsumers and families to set aside a specific timeto talk. Doing so gives consumers and families anopportunity to rehearse the communication skillsthat they learn during FPE sessions.Coping skills training helps consumers and familieslearn new or enhance existing strategies to managestress, problems, or persistent psychiatricsymptoms. Steps used in coping skills traininginclude the following:1. Identify a problem or persistent symptom.2. Conduct a behavioral analysis to determinesituations in which the symptom is mostdistressing.3. Identify coping skills that consumers usedin the past.4. Evaluate the effectiveness of previouslyused coping skills.5. Increase the use of effective coping skills.6. Identify new coping skills to try.7. Model and practice new coping skills in role plays.8. Gain feedback on the effectiveness of the newcoping skills and the increased use of previouslyused ones.9. Further tailor or adapt the coping strategiesto meet consumers’ needs.Coping strategies range from relaxation tocognitive-behavioral techniques. Practicing newcoping skills is most effective when consumersinvolve family members and other supporters.For more information, see the Illness Managementand Recovery KIT.Issues related to social and vocationalrehabilitationFor consumers who are in the rehabilitation phase,FPE sessions focus on their unique recovery goals.Consumers commonly identify situations that arelikely to cause stress or barriers to achieving theirgoals. Use problem-solving, social skills training,and role plays to address these issues. For moreinformation, see Modules 4 and 5.Engage consumers and familiescontinuouslyEngaging consumers and families in FPE starts themoment that they are referred to the program. It isdifficult, if not impossible, to engage consumersand families in any meaningful way unless youknow their needs and goals. For this reason, wesuggest conducting three or more joining sessionsto build a rapport and a working alliance. Onceconsumers and families are involved in ongoingFPE sessions, your challenge is to focus FPEservices on helping them meet their immediateneeds and goals.The engagement process never stops. Wheneveryou meet with consumers and families, you learnmore about them. If you want consumers andfamilies to stay engaged, you must continue to helpthem progress in a way that is meaningful to them.Module 12 6 The Core Basic Processes Elements of Family and Practice Psychoeducation Principles

Some consumers and families have had negativeexperiences with specific practitioners or withmental health services. Discussing these experiencesduring joining sessions can help to overcome them.It may take some consumers and families a whileto realize that you offer something different fromwhat they have received in the past.At any point, if consumers and families disengagefrom the FPE program, assertively reach out toengage them again. Contact consumers andfamilies on an ongoing basis through a variety ofmeans (by phone, mail, etc.). When appropriate,offer to meet with consumers and families in theirhome or their community. Gently encourage anddemonstrate tolerance of different levels ofreadiness by offering flexible services to meetconsumer and family needs.Complete Progress NotesAfter every FPE session, fill out an FPE ProgressNote to document the services that you provided.The Progress Notes will help you demonstrate thatyou did the following:n Met the goals of each joining session;n Provided all components of the educationalworkshop; andn Followed the structured problem-solvingapproach.Progress Notes also help you track consumerand family goals, and the progress that they maketoward achieving them. Make sure that the goalsconsumers develop in the FPE program arereflected in their treatment plan.Participate in supervisionIt is important for new FPE practitioners toreceive supportive supervision. As part of an FPEteam, you are expected to meet weekly with yourfamily intervention coordinator for individual orgroup supervision. Weekly supervision meetingsare critical to coordinate the timing of joiningsessions and the educational workshop, to answerquestions about the model, and to reinforce FPEskills and techniques.Talk with your family intervention coordinator andfellow FPE practitioners about how to best respondto issues that arise in your FPE sessions. Discussconsumers’ goals and the progress that they aremaking toward their recovery.Every 6 months, your family interventioncoordinator will also present the results andrecommendations from your FPE fidelityassessment. Discuss this information as a teamto determine how your FPE program may beimproved. For more information about the FPEfidelity assessments, see Evaluating Your Programin this KIT.SummaryIn summary, this module introduced the coreprocesses of FPE, including joining withconsumers and families, offering education,and understanding the nature of ongoing FPEsessions. The next module discusses two of theseprocesses—joining sessions and educationalworkshops—in greater detail.Ask your family intervention coordinator for a copyof FPE Progress Notes tailored to each phase of theFPE program.The Core Processes of Family Psychoeducation 7 Module 2

Exercise: Identify Consumers and FamiliesAnswer the following questions to help reinforce your understanding of your agency’s FPE policiesand procedures.1. What are your agency’s policies for identifying and referring consumers to your FPE program?nnnn2. Under what circumstances will consumers be discharged from FPE?The Core Processes of Family Psychoeducation 9 Module 2

Exercise: Introduce Your Programn Role play: Conduct a role play to practice introducing your FPE program. Select three group membersto play the roles of consumer, family, and practitioner.n Group discussion: Discuss how you would engage a family member who is overcoming negativeexperiences with the mental health system.The Core Processes of Family Psychoeducation 11 Module 2

Module 3Joining Sessions and Educational WorkshopsNotes to the family intervention coordinatorPrepare for Module 3:n Make copies of Module 3. Your copyis in this workbook; print additionalcopies from the CD-ROM in the KIT.n Distribute the material to those who areparticipating in your group training. Ask themto read it before meeting as a group.n Make copies of these exercises:o Review Progress Notes for JoiningSessions and Educational Workshopso Practice What You’ve Learned About JoiningSessionsDo not distribute them until the grouptraining. Your copies are in this workbook;print additional copies from the CD-ROM.Conduct your third training session:n When you convene your group, viewthe following segments of PracticeDemonstration Video (approximately30 minutes):o Introductiono Joining with Individuals and Familieso Joining Session 1o Joining Session 2o Joining Session 3o Educational Workshopn Discuss the video and the content of Module 3.n Distribute the exercises and Progress Notes andcomplete them as a groupn Make copies of your agency’sProgress Notes tailored to joiningsessions and educational workshops.Joining Sessions and Educational Workshops 13 Module 3

Training Frontline StaffModule 3: Joining Sessionsand Educational WorkshopsModule 3 provides details on two phases of the Family Psychoeducation program:joining sessions and educational workshops. Completing these phases is essentialto the process of engaging consumers and families both initially and throughoutthe program.Joining sessionsJoining sessions are the first phase in theFamily Psychoeducation (FPE) program.FPE practitioners meet three or moretimes with each FPE consumer and theirrespective family members. Meetingstypically last for 1 hour.The purpose of joining sessions isto build rapport, convey hope, andengage consumers and families ina working alliance.Develop a working allianceJoining means to connect, bring together,or unite. Developing a working alliancewith consumers and families is essentialto providing effective FPE. Agenciesthat shortchange this process often havedifficulties keeping consumers and familiesengaged in FPE services.In these alliances, FPE practitioners askconsumers and families to partner withthem in the treatment process. Consumersand families help carry out the treatment,rather than participate as objectsof treatment.Joining Sessions and Educational Workshops 1 Module 3

Joining Session 1Purpose: To develop a rapport and build a workingalliance with consumers and families.Developing a rapport and building a workingalliance is a long process. It is important to buildthe relationship beyond the illness, so keep yourmanner positive, informal, and collegial. Begin thejoining session by socializing. After socializing,review the session’s agenda.If your first contact with consumers and theirfamilies is during an acute psychiatric episode,you may have a special opportunity to build astrong working alliance. Respond quickly to theimmediate needs that consumers and familiespresent. Demonstrate willingness to help,especially in concrete ways.Establish yourself as a resource and support.If consumers and families seek particularassistance, offer it. Prompt attention reassuresboth consumers and families and demonstratesyour commitment to partnering with them inconsumers’ recovery process.Do not be afraid to step in and take on roles nottraditionally practiced. You may act as an advocatein navigating the mental health system, make areferral for more services, or even help consumersand families obtain entitlements or benefits.If consumers are not currently experiencing anacute psychiatric episode, review the last episodethat they experienced. Identify precipitating eventsand early warning signs with consumers andfamilies. To do so, guide them through a reviewof the previous weeks. Emphasize any changes inconsumers’ symptoms, thoughts, or feelings duringthat time. These changes—which may be eitherquite apparent or barely noticeable—constitute theprodromal signs and symptoms for that consumer.In most cases, idiosyncratic behaviors come beforemore common prodromal symptoms, for example,poor sleep, anorexia, pacing, restless behaviors,and irritability. These behaviors become even moreimportant in the future to help prevent relapse.Next, ask both consumers and their families howthey coped with symptoms. Explore the types ofstrategies that were helpful and those that werenot. It is important to understand consumers’ andfamilies’ unique experiences with mental illnesses.Managing an acute psychiatric episode is always adifficult experience. Show that you appreciate thisfact and validate the feelings that consumers andfamilies share. Relate in a humanistic, caring, andhopeful manner.Some practitioners skip or shorten this phase of theFPE program to more rapidly begin clinical work.However, shortchanging this step usually backfiressince consumers and families who do not completejoining sessions are more likely to disengageprematurely from FPE services.Tasks for Joining Session 1n Socialize.n Review a present (or past) acute psychiatricepisode.n Identify precipitating events.n Explore prodromal signs and symptoms.n Review family experiences in providingsupport and validate their experience asnormal human responses.n Identify consumer and family strengths andcoping strategies that have been successful.n Identify coping strategies that have notbeen helpful.n Socialize.Joining Sessions and Educational Workshops 3 Module 3

Joining Session 2Purpose: To explore the emotional impact of seriousmental illnesses.In general, you may conduct joining sessions eitherjointly or separately, depending on consumer andfamily preference. However, hearing aboutfamilies’ frustration and anger about the effectsof consumers’ symptoms is usually best donein an individual session. For this reason, FPEpractitioners often choose to conduct this sessionseparately for consumers and their families.Begin and end each joining session by socializingto reduce anxiety and set the tone for developinga working alliance. Encourage consumers andfamilies to discuss the impact that serious mentalillnesses have had on their lives. Support, validate,and recognize normal human reactions such asfeelings of loss, despair, grief, anger, frustration,and guilt associated with serious mental illnesses.consumers and families overcome past negativeexperiences and allow progress to be made.Many consumers and family members feel thatmental health practitioners blame and criticizethem. Blaming consumers or families for theillness is not constructive or helpful and shouldbe avoided.Share basic information about consumers’ mentalillnesses. Demonstrate the resources that you haveto offer while showing respect for consumers’and families’ first-hand experience in managingtheir illnesses.Convey optimism that consumers will be able toreduce relapses and achieve their personal recoverygoals by partnering in the treatment process.Having answers for every question is less importantthan conveying a commitment to working togetherto find solutions.Next, learn about consumers’ social supportnetwork. You may complete a genogram (a visualrepresentation of family relationships simialrto a family tree) during the session. Rememberto define social supports broadly by includingneighbors, landlords, employers, or any othersupportive people.It is also important to understand the experiencesthat consumers and families have had with themental health system. When those experiencesare left unexpressed, they can form a barrierto developing a strong working alliance, causerepetitive complaints, and hinder your ability towork on current issues. Acknowledge and validatefeelings such as anger or frustration to helpTasks for Joining Session 2n Socialize.n Explore feelings and reactions to havinga mental illness or a relative with a mentalillness.n Identify consumers’ social support network.n Construct a genogram or family tree.n Review past experiences with the mentalhealth system.n Convey basic information about theconsumer’s specific mental illness.n Socialize.Module 13 4 Joining Basic Sessions Elements and Educational and Practice Workshops Principles

Joining Session 3Purpose: To identify consumer and family strengths,interests, and goals and to introduce the nextphases of the FPE program.If you schedule consumers and their families tomeet separately for this session, consider meetingwith consumers first. After exploring consumers’strengths and interests, work with them to identifygoals they would like to work on during the FPEprogram. Setting and pursuing personal goals is anessential part of recovery. In FPE, consumersdefine what recovery means to them and identifythree short- and long-term goals.Explain to consumers that people are often moreeffective in getting what they want when they setclear goals. Help consumers identify goals byreviewing areas of their lives with which they aresatisfied and those that they wish to change. Onceconsumers identify one or two areas on which theywould like to work, help them break the areas downinto smaller goals or steps that can be achievedwithin the next few months. Start with goals thatare relatively small.Introduce consumers to the last two phases of theprogram—the 1-day educational workshop andongoing FPE services. Describe the benefits ofgiving information to family members and say thatyou would like to invite family members to attendthe 1-day educational workshop. Tell them aboutthe format and components of the standardizededucational curriculum. If your agency plans toinvolve consumers in part of the workshop or tooffer a parallel workshop for them, describe thosedetails and invite consumers to attend.Next, describe the last phase—ongoing FPEsessions. Review the goals that consumers identifiedearlier and ascertain their support for working onthem. Explain that ongoing FPE sessions will focuson supporting their efforts to achieve those goals.Introduce the structured problem-solving approachand explain that this is one tool they can use topursue personal goals. Ask consumers if you mayshare their interests and goals with their familymembers. Tell them that you may offer ongoingFPE sessions in a single-family or multifamilygroup format and describe the benefits ofparticipating in multifamily groups. Ask if theywould be willing to participate with their families.If consumers are unsure, continue to explore thedecision during additional single-family sessions.Once consumers give their permission to sharetheir interests and goals with family members,meet with their family member for a third joiningsession. Review consumers’ interests and goals andascertain family support for those goals. If familygoals differ from the consumer’s goals, probe tofully understand the differences. When possible,search for common ground.Next, introduce family members to the last twophases of the FPE program. Review the benefitsof participating in the workshop and multifamilygroup sessions. Ask about their experiences inattending group sessions and what concerns theymight have, including confidentiality, shyness,and feeling pressured to speak in groups or in theworkshop. Assure them that they may contributeonly as much as they wish. If families are unsureabout continuing with the next two phases of theFPE program, schedule additional joining sessionsas needed to continue the engagement process.Tasks for Joining Session 3n Socialize.n Identify personal strengths, hobbies,interests.n Identify short- and long-term goals.n Introduce the next phases of the FPEprogram.n Socialize.Joining Sessions and Educational Workshops 5 Module 3

Pacing and formatThe pacing of joining sessions and whether you willbe able to complete these tasks in three sessionswill depend on individual circumstances. Forexample, if a consumer is in crisis, you might needto shorten the initial joining sessions and completethese tasks by conducting additional sessions.You may choose to conduct joining sessions jointlywith consumers and families or with consumersand families separately. As discussed in Module 2,decisions about the format may be influenced byconsumer and family preferences, diagnosis andillness characteristics, and the goals of the session.For example, FPE practitioners often scheduleseparate sessions to discuss highly personal matterssuch as romantic entanglements, drug abuse,or sexual side effects of medications.Others believe that it is easier to engage consumersand families if they have at least one individualjoining session. They believe that doing so allowsconsumers and families to speak more openly.Use your professional discretion for these decisionsand remember to remain flexible and responsive.Educational workshopsEducation is one of the essential ingredientsof FPE. This section introduces you to arecommended standardized curriculum that youmay use to teach families about their relatives’mental illnesses. Information about the timing,structure, and format of the 1-day educationalworkshop is also outlined below.Why offer informational resources?When people do not have accurate informationabout mental illnesses, they may adopt mistakenbeliefs or rely on intuition. Unfortunately, manyeffective interpersonal and rehabilitativeapproaches are often counter-intuitive.Consequently, despite having their relative’s bestinterest in mind, their actions may interfere withrecovery. Therefore, it is important to give familiesthe information and guidance they need to promoterecovery and rehabilitation.Information can help create a shared language thatallows consumers, families, and practitioners towork together. The first message is that no one isto blame for mental illnesses. Blaming consumersor families is not constructive or helpful.Next, families must understand basic informationabout their relative’s serious mental illnesses. Onecritical aspect of family education is that it givesfamilies hope that they will be able to alter thecourse of illness.Module 13 6 Joining Basic Sessions Elements and Educational and Practice Workshops Principles

TimingYou must respond to the immediate needs ofconsumers and families and answer questions asthey arise. For this reason, the educational processbegins during the first joining session and continuesthroughout each phase of the FPE program.While education is ongoing, the main focus oneducation occurs in the second phase of the FPEprogram. Once consumers and their respectivefamily members have completed three or morejoining sessions, invite family members to attenda 1-day or 8-hour educational workshop. Typically,the 1-day workshop is offered to a group offamily members.During the joining sessions, explain the natureand purpose of the workshop. Explain that familymembers will be expected to attend this type ofworkshop only once as a part of their participationin the FPE program.If you offer ongoing FPE sessions in a multifamilygroup format, plan to have the five to eight familieswho will participate in the multifamily group attendthe same workshop. The workshop gives them anopportunity to get acquainted before themultifamily group begins.Schedule the workshop for a time that meets theneeds of family members. Typically, workshopsare held on weekend days.ParticipantsThe workshop is most often conducted solelywith families—not with consumers—to givefamilies a chance to get acquainted. Theopportunity to interact with others who are insimilar situations and to speak freely about theirexperiences allows families to bond and developsupportive relationships. It also increases families’commitment to participate in FPE.Some agencies involve consumers in part of theworkshop to ensure that they receive the sameeducational information as their families. Othersoffer this information to consumers individuallyor in a separate consumer forum. For moreinformation about providing information aboutmental illness to consumers, see the IllnessManagement and Recovery KIT.Educational curriculumWe recommend using the following standardizedcurriculum to teach families about mental illnesses.To provide enough specific information, werecommend that workshops focus on one specificmental illness. For example, all family memberswould have relatives with schizophrenic disordersand the information presented would relateprimarily to these disorders.The Educational Curriculum CoversSix Topicsn Psychobiology of the specific mentalillness including the basics of brainfunction and dysfunction, and the possiblecauses of the mental illnessn Diagnosis including symptoms andprognosisn Treatment and rehabilitation includingan overview of treatment options and howthey promote effective coping and illnessmanagement strategiesn Impact of mental illnesses on thefamily including how mental illnessesaffect families as a wholen Relapse prevention including prodromalsigns and symptoms, and the role of stressin precipitating episodesn Family guidelines or recommendedresponses to help families maintain ahome environment that promotes relapsepreventionJoining Sessions and Educational Workshops 7 Module 3

Presenter selectionFamily members often feel more comfortable if thepractitioner who knows them and their consumerrelative facilitates the workshop. For this reason,we recommend that the same FPE practitionersconduct the joining sessions, educational workshop,and ongoing FPE sessions.Two FPE practitioners usually facilitate theworkshop. Facilitators are not expected to beexperts in all areas of the educational curriculum.Instead, they choose to present areas in whichthey are comfortable and invite colleagues withparticular areas of expertise to present theremaining educational components. For example,the treating psychiatrist should present the materialon the psychobiology of the specific mental illness.Once you have selected all of the presenters andassigned them areas of the educational curriculum,schedule a practice presentation to review thematerials before the workshop. Practicing withcolleagues helps increase confidence and givesan opportunity for feedback on clarity and rate ofspeech. It may help to videotape or audiotape thepractice presentations and to rehearse responsesto common questions.to make to the learning process and that you areinterested in what they say.Present the material in a conversational tone bysummarizing the key points and giving relevantexamples. Avoid the monotony of having just oneperson speak. At all times, communication shouldbe two-way; it must never seem like a lecture.People learn information by actively processingit in a discussion with someone else.Periodically review information that youalready coveredBegin and end each segment with a brief summaryof the key points. Make connections betweenpreviously learned and new material. To check ifconsumers and families retained the informationand to reinforce topics that you previouslydiscussed, ask them to summarize whatthey remember.Adopt common language to facilitatecommunicationPeople have their own ways of understanding theirexperiences, thinking about their lives, and lookinginto the future. The more you can speak the samelanguage, the easier it will be to make connectionsand avoid unnecessary misunderstandings.Educational techniquesThe roles of educator may be new for FPEpractitioners. When educating consumers andfamilies, keep the following techniques in mind:Use an interactive, not didactic teaching styleTeaching in an interactive style makes learningan interesting, lively activity. Interactive learninginvolves frequently pausing when presentinginformation to get consumer and family reactionsand perspectives. Talk about what the informationmeans and answer any questions that may arise.An interactive teaching style conveys to consumersand families that they have important contributionsBreak information down into small chunksSome mental illnesses cause impairment incognitive functioning, which can result in a slowerrate of processing and the need to presentinformation in very small chunks or in a simplifiedformat. When educating consumers, take intoaccount individual needs.Consumers who are experiencing psychiatricsymptoms may need information to be presentedin different formats, individually, or in shortergroup sessions. By presenting small amounts ofinformation at a time, consumers can learn at theirown pace.Module 13 8 Joining Basic Sessions Elements and Educational and Practice Workshops Principles

Check for understandingHow often you check for understanding of theinformation will vary from person to person.Avoid asking yes or no questions. Have consumersand families summarize information in their ownwords. Hearing them explain their understandingof basic concepts allows you to know which areasthey understood and which need clarification.Multimedia educationOffer the information in the standardizedcurriculum to families in a variety of formats suchas videos, slide presentations, lectures, discussion,and question-and-answer periods. Give each familymember a folder with handouts of the informationthat will be presented, as well as resource lists andWeb sites that they can use to find more information.For example, you might want to include a copyof the following Family Guidelines. During thesession, review each guideline in detail, and askfamily members for their reactions, questions, andexperiences. Illustrate the guidelines with examplesbased on the kinds of problems that your familiesdescribed during joining sessions.Family Guidelines1. Go slow. Recovery takes time. Things willget better in their own time.2. Keep it cool. Enthusiasm is normal. Toneit down. Disagreement is normal. Tone itdown, too.3. Give each other space. Time out isimportant for everyone. It’s okay to reachout. It’s okay to say, “No.”4. Set limits. Everyone needs to know whatthe rules are. A few good rules keepthings clear.5. Ignore what you can’t change. Letsome things slide. Don’t ignore violence.6. Keep it simple. Say what you have to sayclearly, calmly, and positively.7. Partner with your relative’s treatmentteam. Understand your relative’s goalsand the steps outlined in their treatmentplan.8. Carry on business as usual. Re-establishfamily routines as quickly as possible. Stayin touch with family and friends.9. Do not use street drugs or alcohol.They make symptoms worse, can causerelapses, and prevent recovery.10. Pick up on early warning signs.Note changes. Consult with yourconsumer relative and the treatmentteam, if possible.11. Solve problems step by step. Makechanges incrementally. Work on one thingat a time.12. Adjust expectations. Use a personalyardstick. Compare this month to lastmonth rather than to last year or next year.Joining Sessions and Educational Workshops 9 Module 3

Tailor your curriculumWhile we recommend that you follow astandardized curriculum, your workshop will bemost effective if you tailor the information as muchas possible to the participants. Connecting familieswho have relatives with similar diagnoses is onlythe first step. Pay close attention to the educationalneeds that families reveal in joining sessions andemphasize this information in the workshop.Responding to family needs is the key to keepingthem engaged in the FPE program.To ensure that all components of the standardizedcurriculum are covered, follow the agenda below.Sample Agenda of the Educational Workshop9:00–9:15 Coffee and socializing9:15–9:30 Formal introductions and explanationof the format for the day9:30–10:30 Psychobiology and diagnosisof the specific mental illnessBasics of brain function and dysfunctionPossible causes of the specific mental illnessDiagnosisSymptomsPrognosis10:30–10:45 Coffee break and socializing10:45–11:15 Psychiatric medications How they workOutcomesSide effects11:15–12:00 Other treatments options Overview of other treatment optionsHow they workOutcomes12:00–1:00 Lunch and socializing1:00–3:00 The impact of mental illnesson the familyThe needs of the consumerThe needs of the familyCommon family reactions to the illnessCommon problems that consumers and families faceWhat the family can do to helpFamily guidelinesThe problem-solving method3:30–4:00 Wrap Up Question and answer periodAgenda adapted from Anderson et al., 1986, p. 76.Scheduling, logistical, and questions aboutmultifamily group sessionsSocializingModule 13 10 Joining Basic Sessions Elements and Educational and Practice Workshops Principles

To start, offer refreshments in an informal setting toprompt spontaneous socializing. Have refreshmentsavailable throughout the workshop. To develop anatmosphere of partnership, during the breaks makesure that you spend time with families, not solelywith colleagues.To start the formal program, introduce yourself,distribute the educational packets, and explainthe day’s agenda. For example, say:Welcome and thank you for coming on this beautifulSaturday morning! My name is Bob Smith and thisis Peg Rutherford. Some of you already know usbecause we’ve been meeting individually for quitesome time now.We want you to know as much as possible about thisillness—what’s known, and what’s not known, as ofnow. Schizophrenia is a very complex and confusingillness. We have found that the more informationfamily members have, the better equipped they areto deal with problems as they occur.This workshop is only one step of our work together.After the workshop, we will regularly meet as agroup of families and consumers. We will continueto give you relevant information and assistance.We have found with the FPE program that workingtogether with consumers and families results in fewerrelapses and rehospitalizations.We will answer as many questions as possible in thisworkshop today. If we cannot answer something, wewill find someone who knows the information andwill get back to you.While it is important to cover all components ofthe standardized curriculum, present informationin an open, collegial manner that encouragesparticipation. Create an atmosphere thatencourages families to comfortably ask questionsand tailor the curriculum to respond to their needs.It is important to continue the engagement processand strengthen the working alliance.By sharing experiences, families will discoverthat their problems are similar. This realizationnormalizes families’ experience with mentalillnesses and counters feelings of isolation.They often begin to bond during the workshopand build a strong social support network throughtheir contact in the multifamily group.Invite family members to talk about their reactionsto the information presented. Some commonreactions are relief at finally knowing some facts,anger at being kept in the dark, sadness, despair,hopefulness about this approach, and eagernessto get on with the work.Keep in mind that family members are notobligated to speak during the workshop. Respectfamilies’ decisions about how much they wish toshare by encouraging discussion and elicitingreactions without demanding them.If you have not done so already, outline the formatfor multifamily groups, emphasizing the structuredproblem-solving approach and its usefulness forconsumers and families. Present the agenda for thefirst two meetings to generate enthusiasm forupcoming sessions.Give examples of how life has improved forconsumers and families who have participatedin FPE. End the workshop on a positive note. Ifpossible, families should leave the workshop feelingoptimistic about being involved in the FPE program.If you have not done so already, share contactinformation in case families need to reach youbetween sessions. Make sure that you haveresponded to the questions and concerns thatfamilies have raised, especially questions about theupcoming multifamily group. Thank all participantsfor coming to the workshop.This workshop is modeled after the workshopdescribed by Anderson and colleagues (1986).For more information about conductingeducational workshops with consumers andfamilies, see The Evidence in this KIT.Joining Sessions and Educational Workshops 11 Module 3

Exercise: Review Progress Notes for Joining Sessions and Educational WorkshopsDistribute a copy of your agency’s FPE Progress Notes for joining sessions and educational workshops.Review the components of these forms and discuss as a group.Joining Sessions and Educational Workshops 13 Module 3

Exercise: Practice What You’ve Learned About Joining SessionsSelect three members of your training group to play the roles of practitioner, consumer, and family member.Conduct role plays of Joining Sessions 1, 2, and 3.Discuss the following:n How would you engage a consumer who is reluctant to involve a family member in the FPEprogram?n How would you respond if consumers or family members become upset when discussing howmental illness has affected their lives?n How would you respond to a consumer or family member who shares past negative experienceswith group sessions?Joining Sessions and Educational Workshops 15 Module 3

Module 4Ongoing Family Psychoeducation SessionsNotes to the family intervention coordinatorPrepare for Module 4:n Make copies of Module 4. Your copyis in this workbook; print additionalcopies from the CD-ROM in the KIT.n Distribute the material to those who areparticipating in your group training. Askthem to read it before the group training.n Make copies of the followingexercises:o Practice What You’ve Learned AboutMultifamily Groupso Review the Progress Note for Ongoing FamilyPsychoeducation SessionsConduct your fourth training sessionn When you convene your group, viewthe last two segments on the PracticeDemonstration Video (approximately50 minutes):n Multifamily Groupso Problem-Solvingo Discuss the video and content of Module 4.n Distribute the exercises to the group andcomplete themDo not distribute them until the grouptraining. Your copies are in this workbook;print additional copies from the CD-ROM inthe KIT.n Make copies of your agency’s Progress Notes forongoing FPE sessions (if available). For a modelform, see Building Your Program in this KIT.Ongoing Family Psychoeducation Sessions 17 Module 4

Training Frontline StaffModule 4: Ongoing Family PsychoeducationSessionsModule 4 describes the last phase of the program—ongoing Family Psychoeducationsessions. When possible, these sessions should be offered in the multifamilygroup format. For this reason, the module describes the first three sessions of themultifamily group sessions in detail and draws applications to the single-family model.Conduct ongoing FamilyPsychoeducation sessionsOnce consumers and families havecompleted three or more joining sessionsand families have participated in the 1-dayeducational workshop, invite consumersand families to attend ongoing FamilyPsychoeducation (FPE) sessions.You may conduct these sessions in eitherthe single-family or multifamily groupformat. Since you discuss and select formatoptions with consumers and families duringjoining sessions, information for selectinga format is presented in Module 2.When possible, offer ongoing FPE sessionsin a multifamily group format. Multifamilygroups consist of five to eight consumersand their respective family members.Two FPE practitioners who have conductedthe joining sessions and educationalworkshop facilitate the sessions.Multifamily groups meet every 2 weeksfor 1½ hours. For consumers and familiesto gain the full effectiveness of the FPEprogram, offer ongoing FPE sessionsin either format for 9 months or more.While this phase of the FPE program hasbeen found to be most effective whenoffered long term, many FPE practitionersOngoing Family Psychoeducation Sessions 1 Module 4

do not emphasize the long-term nature of FPEduring the engagement process. Asking consumersand families to commit long term may provokeanxiety. For this reason, tell consumers and familiesthat this last phase of the FPE program willcontinue for as long as they find it helpful.Through the joining sessions, you developeda working alliance with consumers and familiesin the group. In the first two multifamily groupsessions, you will extend that partnership by givinggroup members an opportunity to bond and buildtheir group identity.Structure of multifamily groupsThe structure of the first two multifamily groupsessions differs from the structure of later sessions.In the first two sessions, the goal is to establisha partnership among group members. Up to thispoint, the working alliance has been limited tothe consumer, family, and practitioner. Whenconsumers and families begin participating inmultifamily groups, the goal is to extend theworking alliance to include all group members.Why structure the first two groupsdifferently?Consumers and families need to get to know oneanother apart from the effects of mental illnesseson their lives. The first two sessions are designedto help group members learn about one anotherand bond as a group.Traditional group therapy models emphasizeexpressing feelings. This often sparks conflictbetween family members, disagreement about thegroup’s purpose, and anger or confrontation withfacilitators. Consequently, consumers and familiesmay become overwhelmed and give up on thegroup. In contrast, FPE focuses on addressingcurrent issues that pose barriers to consumers’personal recovery goals. Group members worktogether by participating in a structured problemsolvingapproach. For this approach to be effective,group members must share ideas and be open toaccepting them. It is best to proceed slowly andtake time to develop trust and empathy.Overview of the first sessionThe goal of the first session is for FPE practitioners,consumers, and family members to get to know oneanother in the best possible light. The first sessionis not intended to be an opportunity to share deepemotions and feelings about the illness or about thegroup itself. Rather, it is a time for group membersto get to know one another and discover commoninterests, issues, and concerns. For this reason,encourage group members to talk about topics thatare unrelated to the illness, such as their personalinterests, hobbies, or daily activities.Set up the roomArrange chairs around a table or in a semi-circleso that group members can easily see and hearone another. Use the same setup at every session.Be aware that once the problem-solving sessionsbegin (after the second group session), groupsoften like to be in a semi-circle so they can seethe blackboard, flipchart, or chalkboard.Have refreshments available to prompt socializingbefore and after the group. At the start of thesession, tell group members that they are freeto move around, get a drink, or use the restroom.Make sure that consumers know they can leavethe room whenever necessary.Module 14 2 Ongoing Basic Family Elements Psychoeducation and Practice Principles Sessions

Be an effective facilitatorDuring the first two group sessions, be a good host.Introduce group members, point out commoninterests, and guide conversations to more personalsubjects such as interests and hobbies.Act as a role model. Demonstrate by example thatyou expect people to talk about topics other thanthe illness. This means that you should be preparedto share a personal story of your own.Pay close attention to group members who speakand thank them when they finish. Prompt reluctantgroup members with questions or encourage themto talk. Some group members may benefit froma slow conversational pace to better absorbinformation that they hear.Think of the group in terms of any group of peoplewho meet one another for the first time. Guide theconversation to topics of general interest such asthe following:n Where people live;n Where they were born and grew up;n What kind of work they do both insideand outside the home;n What their hobbies are;n How they like to spend their leisure time;n Which recent movies they have seen; andn What holiday or vacation plans they have.Structure the first sessionWelcome group members and review the formatfor the first two sessions and future group sessions.Begin with introductions. Group memberscommonly want to talk about the illness duringtheir introduction. Guide the discussion by clearlysetting the agenda for the first group and modelingthe type of introduction that you expect. Forexample, say:Tonight, the goal is to begin to get to know oneanother. Let’s go around the room and each saysomething about ourselves. It is understandable towant to talk about the effects of a mental illness, butwe will get to that during our next meeting.Tonight, the goal is to talk about other parts of ourlives. Let’s start by sharing the things that we areproud of. I would like to start by telling you aboutmyself.If consumers and families have joined thoroughlywith you, they will feel less need to focus on theillness during the first group session. When youparticipate and talk about yourself, it gives thegroup a model and creates a feeling of partnership.Some FPE practitioners find it uncomfortable toshare personal information, since this is a departurefrom the way of conducting traditional therapygroups. However, you must create a friendly,comfortable atmosphere among group members.It may help to rehearse with your co-facilitatorahead of time. Think of a few positive, engagingstories about family, favorite activities, interests,and hobbies.Ongoing Family Psychoeducation Sessions 3 Module 4

Be prepared to talk for about 5 minutes. Forexample, say:Hi, my name is Margaret Hanson. Some of youhave already met me, and some are meeting mefor the first time tonight. I am a social worker andhave worked in the community mental health centerfor 15 years.I grew up in this area and my parents still live inthe house I grew up in. I have three teenage girlswho keep my husband and me very busy andchallenged! Even though the girls are growing upand going in different directions, we still like to dothings together as a family. One thing we like todo is go camping.Over the years, we’ve acquired a lot of equipmentso the girls could each invite a friend along on ourtrips. This summer, we’re planning a trip to the WhiteMountains, and we’re bringing two large canoessince the girls are inviting friends. I especially enjoythese trips since I don’t do much of the cooking—my husband does! It’s so peaceful to camp and tospend time in a less harried environment.We have an old yellow lab that stays home whenwe go camping, but when we’re home, she likesto take me for a walk every morning, usually asthe sun comes up. In my spare time, I garden, scoutflea markets, spend time with friends, sew, and read.Occasionally, my husband and I see a movie, goout to eat with friends, or walk the beach when thetourists aren’t around. Well, that’s enough about mefor now. I’m looking forward to getting to know allof you better as time goes by.Redirect group membersIf group members begin to talk about the illness orthe impact of the illness on their lives, redirect theconversation. For example, say:We will have time to talk about the illness later on.For right now, let’s try to get to know other thingsabout one another.Prompt group membersYou may have to prompt some group memberswho offer only a minimal amount of information.Ask questions to help them give more details. Forexample, if they like to watch television, ask whichshows they watch or if they say they like to cook,ask which recipes they enjoy most. Strive to pointout similarities or interests that group membersshare. For example, say:I notice that several of us like to go to the movies.Maybe we can talk about our most recent favoritefilms.This helps develop relationships and groupcohesion.Then turn to the next person and have groupmembers continue around the circle. Thank groupmembers after they contribute. Have your cofacilitatorsit halfway around the circle and takea turn in sequence.Module 14 4 Ongoing Basic Family Elements Psychoeducation and Practice Principles Sessions

Evaluate Common ProblemsSafety issuesSafety is always of primary importance. As you review the issues, address any potentialthreats to safety.Clarify the issue. If the issue is too emotionally charged or is likely to disrupt the groupprocess, address the issue apart from the group, and update the group about how itwas resolved. Discuss your reasons and plans in as much detail as possible so that groupmembers have the best possible learning experience.If the issue is not too emotionally charged or disruptive and can be broken down intomanageable parts, ask the consumer if you may select the problem for the groupto discuss.Managing symptoms,substance use, andmedication issuesLife eventsReports of actual or potential exacerbation of symptoms are common problems thatyou may address in the group. Issues about medications and substance use are alsoimportant. Because these are potentially emotional issues, present or reframe theproblem in nonblaming terms. Blaming consumers or families is not constructive orhelpful. Modeling a nonjudgmental, nonblaming approach often can be a good learningopportunity for group members.Sometimes, major events occur (for example, divorce, death, marriage, graduation,a birth), that can be unsettling for the whole family and especially for someone withmental illness. It is natural for stress levels to rise at such times, even with positive stress.Changes sometimes occur within mental health agencies, such as a move to anotherbuilding or a practitioner’s resignation that may be as distressing to consumers andfamilies as other major life events. You may be able to address these issues in the group.Disagreementamong consumersand family membersIt is natural for consumers and family members to disagree at times. When exploringissues such as these, consider the following:The intensity of the disagreementSometimes an issue surrounded by intense disagreement is better resolved in singlefamilysessions. In such a case, suggest an outside meeting to help with the problem.If the disagreement does not seem extreme and is selected for problem-solving, keepcriticism and emotions to a minimum. Consider reviewing the Family Guidelinesoutlined in Module 3.Whether the disagreement is a consequence of the mental illnessIf the disagreement is a consequence of the mental illness, problem-solving in thegroup can be helpful and elicit solutions that are pragmatic and stress-reducing.However, when a consumer and family member are disagreeing, it may be difficult toagree on the definition of the problem. One approach is to define the problem broadly,such as: How can the Smith family manage their disagreement so that John will not beoverwhelmed and relapse?Ongoing Family Psychoeducation Sessions 9 Module 4

Define the problemThe next step is to ask consumers and familiesfor more information to help the group clearlyunderstand and define the problem. Ask detailedquestions such as the following:n What is the current issue?n When did you first notice the problem?n When does it occur? How often?In what situations?n Has the problem changed in any way recently?n Whom does the problem affect? How?n With what activities does the problem interfere?n What have you tried to alleviate the problem?What were the results?n Who seems to have the most impact on theproblem?Seek consensus on the definition of the problemby summarizing it in a single sentence or phraseand asking consumers and families if the definitionmakes sense to them. Make sure that you accuratelydefine the problem. Incorrectly phrasing theproblem can cause the group to generateineffective solutions. For example, consumersor family members may indicate that the personis the problem. Remember, the problem is theproblem; the person is never the problem.Once a problem has been defined in a way that isacceptable to each member of the family, write iton the blackboard.Generate solutionsOnce you define the problem, ask group membersto offer whatever solution they think may help.Do not evaluate solutions now since doing sodramatically reduces the number of solutionspeople present. It is often helpful to say:We know it is difficult to resist discussing suggestionsas people generate them. However, we have foundthat by discussing them as we go, some solutionsare left unspoken. Therefore, let’s delay evaluatingsolutions until after all suggestions have been made.The goal is to generate as many ideas as possibleabout solving the problem. The more solutionsgenerated, the more likely one will adequatelyaddress the problem. For this reason, ask allgroup members to contribute at least one solution.Take all ideas seriously and write them on theblackboard, even if a suggestion seems wild or silly.It is important that group members feel their ideasare respected and no idea is discounted.Discuss advantages and disadvantagesof each solutionAfter people have presented all their solutions,invite group members to weigh the advantagesand disadvantages of each. On the blackboard,simply write a plus [+] next to the solution whensomeone identifies an advantage and a minus [-]after the solution when someone identifies adisadvantage. When possible, take time to evaluatethe solutions as a group. When time is short, somefacilitators streamline the evaluation process bypresenting the solutions to the group to reviewand select. Unfortunately, when this process isshortchanged, consumers do not fully benefit fromthe others’ experiences.Choose the best solutionWhen you evaluate all solutions, review the listemphasizing solutions that have the most advantagesand fewest disadvantages. Then ask consumerswhich solutions they would like to test forthemselves over the next 2 weeks. Stress that testingsolutions is for the benefit of everyone in the groupbecause everyone is looking for solutions that work.Module 14 10 Ongoing Basic Family Elements Psychoeducation and Practice Principles Sessions

Form an action planOnce you select a solution, develop a detailedaction plan. Typically, you will break the solutiondown into small steps or tasks. Specify each stepby asking:n What needs to happen first?n Who will do that step?n When will that step happen?n Where will people meet for that step?Discuss each step or task and assign someoneresponsibility for completing it by a specific date.Some plans include tasks that all group membersmay try. Others are designed specifically for theconsumer and family who presented the problem.Once you develop the action plan, have your cofacilitatorrecord the steps on a Progress Note form.Make copies for the consumer’s chart and for theconsumer and family.Review the action planWhen appropriate, tell the consumer and familythat you may check on their progress during thecoming week and that you are available for help.Remind them that the group will look forwardto an update during the next session.At the beginning of the next session (during the goaround),review the action plan and followup on theconsumer’s progress. Ask:n What steps were completed?n What went well?n What did not go so well?Praise all efforts and point out any progress.If steps were not completed, explore obstaclesand alternatives. If consumers encounteredsignificant challenges that cannot be resolvedquickly, suggest meeting individually with theconsumer and family outside the group to explorethe issue in greater detail. When possible, updatethe group about the outcome to ensure that otherscan learn from the experience.Ongoing Family Psychoeducation Sessions 11 Module 4

Difficulties encounteredAt any point during the group, if consumers orfamilies who have identified the problem beginto struggle with the process, make sure you haveaccurately defined the problem and that the groupis addressing the true problem. It is better to stopthe process and clarify the problem definition thanto generate solutions that are irrelevant to the currentissues that consumers and families are facing.Many issues that the group presents are perceivedas unsolvable. These are often long-standingproblems that have resisted all attempts to makethem better. Group members seldom have muchhope that things will change. With this in mind,collect as much information as possible when youselect and define problems so that you may breaklarge problems down into smaller parts and workon them incrementally. When things do change,acknowledge the efforts of those involved inthe change.In some instances, stray from thestructured problem-solving approachUse the problem-solving approach for mostmultifamily group sessions. However, occasionallygroup members may identify issues that are bestaddressed with a different approach. In this case,alter the approach by bringing in guest speakersor by offering specific skills training. For example,research shows that interspersing skills trainingtargeted to the symptoms of obsessive-compulsivedisorder is an effective adaptation of FPE forfamilies and consumers with this illness (VanNoppen, 1999).Throughout the FPE program, continue to shareeducational materials targeted to specific mentalillnesses in different formats (for example, video,print, and website resources). Remaining responsiveto the needs of consumers and families will keepthem engaged in FPE services.When needed, offer ongoingFamily Psychoeducation servicesin a single-family formatYou can easily adapt the goals of ongoingmultifamily sessions to the single-family format.Introduce consumers and families to the structuredproblem-solving approach and work with themto identify current issues that may be addressedcollaboratively. Follow the guidelines describedin the multifamily group format.While consumers and families will not have thebenefit of other group members’ experiences, itis still possible to identify strengths, resources,and strategies that have worked in the past. Withconsumers and families, generate solutions andevaluate each one to select the best choice. Next,collaborate with the consumer and family todevelop a detailed action plan.Tailor single-family sessions to the needs of theconsumer and family. Keep your work withconsumers and families task oriented and focusedon consumers’ personal recovery goals. For moreresources on the single-family format, see TheEvidence in this KIT.Module 14 12 Ongoing Basic Family Elements Psychoeducation and Practice Principles Sessions

Exercise: Practice What You’ve Learned About Multifamily Groupsn Role play: Conduct a role play to practice introducing the format of the first two multifamily groupsessions. Practice how you may introduce yourself during the first group session.n Group discussion: Discuss as a group how you would redirect a consumer or family member who becomesupset during the second multifamily group session.Ongoing Family Psychoeducation Sessions 13 Module 4

Exercise: Review the Progress Note for Ongoing Family Psychoeducation SessionsDistribute a copy of your agency’s Progress Note for ongoing FPE sessions. Review the components of thisform and discuss as a group.Ongoing Family Psychoeducation Sessions 15 Module 4

Module 5Problem Solutions from Actual PracticeNotes to the family intervention coordinatorPrepare for Module 5:n Make copies of Module 5. Your copyis in this workbook; print additionalcopies from the CD-ROM in the KIT.n Distribute the material to those who areparticipating in your group training. Askthem to read it before the group training.Conduct your fifth training session:n Discuss the content of Module 5.n Distribute the exercise and completeit as a group.Note: This module has no corresponding PracticeDemonstration Video component.n Make copies of the followingexercise:o Practice What You’ve LearnedAbout Problem-SolvingDo not distribute them until the grouptraining. Your copies are in this workbook;print additional copies from the CD-ROMin the KIT.Problem Solutions from Actual Practice 17 Module 5

Training Frontline StaffModule 5: Problem Solutions from Actual PracticeModule 5 presents case studies of actual multifamily groups and catalogues avariety of responses to two commonly presented issues: finding or keeping a joband using medications. Although these examples capture problems and solutionsthat have emerged from real groups, they also apply to single-family sessions.Overview of the moduleEvery group is unique. One approach willnot solve all difficulties that consumers andfamilies face. To be successful, solutionsmust be relevant and acceptable toconsumers and families. This modulepresents the experiences of those who haveparticipated in FPE programs. We selectedtwo areas—employment-related andmedication-related issues—becausethey are commonly raised and especiallychallenging. Also, they are a frequentsource of tension and conflict forconsumers, families, and practitioners.Disagreements can be destabilizing or,at least, can prevent rehabilitation if leftunresolved. Rather than trying to resolvedisagreements directly, the structuredproblem-solving approach allowspractitioners, consumers, and familiesto alleviate the effects of conflicts byfinding alternative paths or identifyingcommon ground.Problem Solutions from Actual Practice 1 Module 5

Employment issuesThis section begins with two case studies that showyou how the problem-solving approach has beenused to define and address employment-relatedissues. It also presents a log of similar problemsand solutions identified through FPE multifamilygroups. In some cases, staff from evidence-basedpractice Supported Employment programs haveco-facilitated these groups.Pedro’s storyStep 1Pedro, a man in his mid-30s, has struggled withserious mental illnesses since his late teens. He hasbeen able to maintain an apartment and stay onmedication for years with minimal support, butuntil recently had been unemployed. He is workingclosely with an employment specialist to make hispart-time job successful, but shares some concernswith the multifamily group.Define the problemIn Step 1, the goal is to narrow the definition of theproblem so that the group can generate practical,concrete solutions. To better understand Pedro’sconcerns, the facilitator asked him to talk about histypical workday. Next, the facilitator asked Pedro’ssister more questions to understand her perspective.This process revealed that, since Pedro had not hadmuch work experience, he was uncomfortable withco-workers. The facilitator defined the problem as:How can Pedro become more comfortable with hisco-workers?Pedro and his sister agreed with the definition ofthe problem and the co-facilitator wrote it on theblackboard.Step 2 Generate solutionsAll members of the group brainstormed andgenerated the following list:n Tell yourself there’s no pressure to be friendswith everyone.n Ask for support.n Connect with people who do the same job.n Do the best job you can.n Plan activities outside of work.n Make small talk.n Compliment people.n Give yourself credit.n Use humor.n Join work-related activities such as lunch.n Bring in food to share.n Ask questions to get to know others.Step 3 Discuss advantages and disadvantagesThe facilitator read each solution aloud and askedgroup members:What are the main advantages of this solution?After the co-facilitator recorded the advantages,the facilitator asked, “What are the disadvantagesof this solution?” The co-facilitator wrote allresponses on the blackboard.Step 4 Choose the best solutionThe facilitator reviewed the solutions for which thedisadvantages outweighed the advantages. In thesecases, the group agreed to cross out these solutions.Of the remaining solutions, the facilitator askedPedro which he would like to try. Pedro chose thefollowing solutions; his sister agreed that they aregood ones to try:n Join a work-related activity; andn Bring in food to share.Module 5 2 Problem Solutions from Actual Practice

Step 5 Form an action planThe group helped Pedro break the solutionsthat he chose down into manageable, concrete,specific steps.Pedro’s Action PlanStep 6 Review the action planIn the go-round of the next group meeting, thefacilitator asked Pedro about his experience inworking on his action plan. The group learned thatPedro set aside the grocery money, made a shoppinglist, and bought the ingredients for apricot bread.Unfortunately, he burned the bread and was unableto bake a second loaf before work on Sunday.n Set aside grocery money.n Make a shopping list.n Shop for apricot bread ingredients duringthe week.n Bake bread on Saturday afternoon.Although he didn’t have any bread to share, hedid join his co-workers for lunch. He shared hisbreadmaking story and his co-workers laughed.He reported that it helped break the ice and he feltmore comfortable with his co-workers. Facilitatorsand group members praised his courage and efforts.n Bring bread to work on Sunday.n Join co-workers for lunch on Sunday.Problem Solutions from Actual Practice 3 Module 5

Sharon’s storySharon is a 38-year-old woman with a schizoaffectivedisorder. She lives alone with her cat and workspart-time (every morning for 4 hours) in themailroom of a large insurance company. The busstop to work is within easy walking distance of herapartment. She likes the routine of working everyday and has become quite efficient at her job, whichdoes not vary too much from day to day. Recently,however, some of her work duties have changed.Step 1 Define the problemThe facilitator asked Sharon to explain how herwork has changed. Sharon explained that thecompany is handling bulk mailings that must go outquickly, increasing tension at the worksite. Sharontold the group that she found the fast pace difficultand stressful. The facilitator defined the problem as:What can Sharon do to feel less overwhelmed atwork when bulk mailings must go out quickly?Sharon and her parents agreed with the problemdefinition and the co-facilitator wrote it on theblackboard.Step 2 Generate solutionsThe facilitator asked group members for possiblesolutions. They generated the following list:n Quit.n Talk to the supervisor.n Set limits for yourself.n Take more frequent breaks.n Go to the gym to relieve tension.n Get a massage.n Reduce your hours at those times.n Scream into a pillow.n Practice stress reduction techniques.n Seek peer support.Step 3 Discuss advantages and disadvantagesThe group discussed the advantages of eachsuggestion first, then the disadvantages. The cofacilitatorwrote all responses on the blackboard.Step 4 Choose the best solutionAfter reviewing the advantages and disadvantages,the group eliminated several solutions. Sharonchose the following solutions; her parents agreedthey are good ones to try:n Talk to your supervisor.n Practice stress reduction techniques.Step 5 Form an action planWith the group’s help, Sharon and her parentsdeveloped the following action plan:n Approach the supervisor first thing in themorning to ask for a meeting time.n Meet with the supervisor.n Use stress reduction techniques before and afterwork for 1 week.Then they conducted a role play in the group soSharon could practice what she wants to say to hersupervisor. Next, the facilitator introduced a stressreduction technique. All group members practicedthe technique once together.Step 6 Review the action planAt the next group session, Sharon reported thatshe had not approached her supervisor duringthe previous 2 weeks. She practiced her stressreduction technique, which she liked. Althoughwork was still tense sometimes, she reported thatshe feels better about it.Module 5 4 Problem Solutions from Actual Practice

The following log outlines other employment-related problems and solutions that FPE multifamilygroups identified.Log of Other Employment-Related Problems and SolutionsProblemFinding workPossible solutionsn Look through want ads.n Walk or drive around the community in search of job openings.n Talk with members of your social support network.n Use the yellow pages to identify jobs of interest.n Visit jobs of interest.n Enroll in a Supported Employment program.Adjusting to a new jobn Prepare for your first day (set an alarm clock, pack lunch, practice a bus route).n Ask questions, as needed, about the job.n Review your written job description.n Arrive early to get comfortable with the place.n Take one day at a time.n Work with an employment specialist.Managing symptomsand stress at workn If symptoms affect your concentration, make notes to remember tasks or instructions.n Ask for an accommodation such as a quiet workspace or regular breaks.n Use stress reduction strategies.n Identify a buddy at work with whom you can talk.n Carry PRN medication.n Work with an employment specialist.Problem Solutions from Actual Practice 5 Module 5

Medication issuesThe following case study shows you how theproblem-solving approach has been used to defineand address medication issues. This section alsopresents a log of other medication-related problemsand solutions identified through FPE multifamilygroups. In some cases, a psychiatrist or nurse cofacilitatedthese groups.Darcy’s storyStep 2 Generate solutionsThe facilitator asked all group members tocontribute possible solutions. The group generatedthe following solutions:n Call the doctor.n Cut down on the medication.n Ask someone to take notes in class.n Bring a tape recorder to class.n Drink coffee.n Ask a classmate to wake her.Darcy is a 29-year-old woman who hasschizoaffective disorder. She is the mother of twoyoung children. It is important to her to functionwell enough to care for her family, as well as totake one course each semester as she works towardher undergraduate degree. Following the adviceof her doctor, Darcy recently started taking a newmedication.Step 1 Define the problemThe facilitator asked Darcy to explain the concernsthat she had about the new medication she is taking.Darcy explained that the medication makes her feeltired. She was unable to concentrate in class andfrequently nodded off.The facilitator defined the problem as:What can Darcy do if she’s experiencing side effectsfrom her medication?Darcy and her family agreed with the problemdefinition and the co-facilitator wrote it onthe blackboard.Step 3 Discuss advantages and disadvantagesThe group discussed the advantages of eachsuggestion first, then the disadvantages. The cofacilitatorwrote all responses on the blackboard.Step 4 Choose the best solutionAfter reviewing the advantages and disadvantages,the group eliminated several solutions. Darcy chosethe following solutions; her family members agreedthey are good ones to try:n Bring a tape recorder to class.n Call the doctor.Step 5 Form an action planWith the group’s help, Darcy and her familydeveloped the following action plan:n After class on Wednesday, Darcy will set up anappointment with her professor. She will tell herprofessor that she is sleepy in class because of theside effects of a medication and she will ask if shecan record the class until her dose is corrected.n Tomorrow morning, Darcy will call to set upan appointment with her doctor. Her familymember agrees to go with her to the appointmentfor support.Module 5 6 Problem Solutions from Actual Practice

Step 6 Review the action planOne week later, the facilitator called Darcy to seehow she is doing and if she needed any help withthe action plan. Darcy reported that she had set upher appointments. They reviewed what she wishedto say during each meeting.At the next group session, Darcy reported that shereceived permission to tape record her class. Shestill fell asleep twice last week but her doctorsuggested taking her medication at night and thatseems to help. Her doctor agreed that she shouldlower the dose of her medication if the side effectscontinue for another 2 weeks.The following log outlines other medication-relatedproblems and solutions that FPE multifamilygroups identified.Log of Other Medication-Related Problems and SolutionsProblemPossible solutionsForgetting to takemedicationsnnnnnTake medications at the same time every day.Set a timer.Combine taking medications with another daily activity such as brushing your teeth.Ask a buddy to call and remind you.Leave yourself a note.Difficult medicationregimesnnnTalk with your doctor to see if your medication schedule can be simplified.Write a schedule on your calendar.Keep a medication record.n Use a pill container. Ask a buddy for help.Communicatingmedication issuesto your doctornnnnnAsk for a longer appointment time.Role-play how you would present your concerns to your doctor.Ask other treatment team members to speak to your doctor with you.Ask a family member to join you for your appointment.Write down your concerns or keep a medication record and share it with your doctor.Many concerns that consumers raise aboutmedications may be viewed as decisional conflicts.In other words, consumers may feel conflictedabout their decision to take medication asprescribed. The structured problem-solvingapproach is an effective way to address suchconcerns as long as consumers agree with the waythat the problem is defined and actively participatein weighing the advantages and disadvantages ofthe solutions generated. It is important to createan environment in which all group members feelcomfortable voicing their ideas and consumers feelsupported in weighing the options and choosing thebest solution.Problem Solutions from Actual Practice 7 Module 5

Exercise: Practice What You’ve Learned About Problem SolvingSelect three members of your training group to play the roles of practitioner, consumer, and family member.Conduct role plays to practice using the structured problem-solving approach in either a single-family ormultifamily group format.n Conduct a role play to address an issue related to employment.n Conduct a role play to address an issue related to medication.Problem Solutions from Actual Practice 9 Module 5

HHS Publication No. SMA-09-4422Printed 200926171.0709.7765020404